Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Would you continue or stop anticoagulation for a DVT/PE in a patient with active cancer who has completed 6 months of therapy?
This is an important question that we didn’t really have a clear answer for… until this year when an NEJM RCT was published! Mahé et al., PMID 40162636 In this RCT, patients with cancer-associated VTE who completed 6 months of full-dose apixaban were randomized to half-dose apixaban vs. full-dos...
How do you approach the treatment of eosinophilic fasciitis refractory to glucocorticoids and methotrexate?
As rheumatologists, we are accustomed to managing people with rare diseases. Eosinophilic fasciitis (EF) ranks among the rarest of the rare, so it is understandable that there are no carefully designed trials assessing the efficacy of the various immune-modulating drugs. Clearly, corticosteroids are...
Are there clinical scenarios in which you might use buspirone on an as-needed basis for older adult patients?
I have not generally used buspirone as an as-needed medication for older adults experiencing anxiety. I will use it as an adjunct to other medication management, SSRIs, if needed [1]. However, its effect is generally seen with consistent dosing, and even then, the effect may not be realized for many...
How, if at all, have you changed your approach to the use of escitalopram for agitation in Alzheimer's dementia based on results from the S-CitAD RCT?
The S-CitAD trial results have changed preference from escitalopram over citalopram to citalopram over escitalopram. Citalopram is R-enatiomer and escitalopram is the S-enantiomer. This study was underpowered due to difficulty in recruitment and randomized only 173 patients rather than the intended ...
What is your preferred approach in treating recurrent bleeding from GAVE?
If repeated APC has not helped, I ask our advanced endoscopists to perform RFA. If it is a nodular GAVE, then banding is another option.
How do you approach DOAC dose reduction for secondary prophylaxis of VTE in cancer-associated thrombosis?
Data from the API-CAT trial (Mahé et al., PMID 40162636) show that de-escalation of apixaban after 6 months was non-inferior compared to the standard dose with respect to recurrent VTE. Although there was no difference in major bleeding, the lower dose of apixaban was superior from the clinically re...
What is your approach to a situation where DILI is suspected secondary to an important medication (e.g., anticoagulation, antibiotics, etc.), but the diagnosis is uncertain and the liver injury is relatively mild?
If the drug suspected to induce liver injury causes symptoms and ALT is >3 times the upper limit of normal (ULN), I would stop the drug and find an alternative. Even if no symptoms are present, I would stop if ALT is >5 times ULN. Any level increase of ALT below the above parameters would still requ...
What is your approach to a situation where DILI is suspected secondary to an important medication (e.g., anticoagulation, antibiotics, etc.), but the diagnosis is uncertain and the liver injury is relatively mild?
If the drug suspected to induce liver injury causes symptoms and ALT is >3 times the upper limit of normal (ULN), I would stop the drug and find an alternative. Even if no symptoms are present, I would stop if ALT is >5 times ULN. Any level increase of ALT below the above parameters would still requ...
How do you decide when to act upon TFT derangements in hospitalized patients (e.g., start/adjust thyroid replacement therapy) vs attribute to NTIS (formerly euthyroid sick syndrome) and advise repeat TFTs as an outpatient?
It is not always easy to discern, but typically in NTIS, T3, T4, and TSH are all low or normal (TSH may be slightly elevated but not markedly elevated). True hypothyroid (requiring new medication or adjustments of existing medications) typically has a high TSH and low Free T4, and the patient may ha...
How do you decide whether to hold chronic medications with sedation potential in patients presenting with acute encephalopathy?
As soon as the patient comes, I recommend medication levels where possible to decide if essential medications with sedation potential should be stopped. Also, basic labs to get to the cause of the mental status change, including the scans and an EEG. In case all that is not possible, then depending ...